Randi Mundell’s CS Cluster

Comprehensive Program ReviewAugust 17, 2012

Athol, Brookfield, Paxton, Westboro, Windsor

CLUSTER HIGHLIGHTS Athol, Brookfield, Paxton, Westboro, Windsor

Unified team (staff) within programs that are distant from each other◦ Flexible in schedule to meet program needs and

individual needs during staff shortages and incidents

Windsor staff found bikes for individuals to help increase activity and promote healthy living, with no cost to program

All CT women involved in vocational programming and all Brookfield women involved in day programming

CLUSTER HIGHLIGHTS continued

Volunteer Opportunities for individuals:o Sherry House (clothing drive) ◦ Walk for Hunger (walked)o Habitat for Humanity (clean/stock) ◦ KOC (cleaning)o Local animal shelter (walked dogs)◦ Self-advocacy fund raiser o Local nursing home (serving food and companion)o Wrote letters to Soldiers and Malia (terminally ill child)

Community Involvement for individuals - INCREASED◦ Brookfield Bowling League – ALL 5 women◦ Horseback Riding lessons and horse show ◦ Paxton family cookout◦ Local gyms; churches memberships◦ Art and Music classes; guitar lessons ; dance classes and recitals ◦ art shows; museums; knitting classes (at local community center)◦ Small mechanics class (rebuilding go-carts); and enrolled in fall

college automotive courses

Far distance away from Shirley and Boston and other CS programs◦ Staff coverage is difficult due to this◦ Lack of interaction with others

CT staff are not required to complete a full Medication training as compared to MA staff◦ Increase in medication occurrences and incidents

Client medication refusals Staff turn over Funds needed for meaningful day supplies Integration of new intakes with peers and program

◦ Time consuming for staff and program◦ Limits staff involvement with other individuals, can lead to

increased behaviors◦ Difficulties trying to find common interests

Areas in Need of Improvement

STAFFINGOVERDUE PERFORMANCE EVALUATIONS

Data obtained from HR Department & HR Personnel Summary

0

1

2

3

4

5

6

4.5

1.6

4

0.5

6

3.32

Average: 3.3 Overdue FT Performance Evaluations January – June 2012

** Westboro – data from May & June only.

As of June 30, 2012, only 1 PT evaluation was overdue for the cluster.

Last CPR, average: 2.2 for overdue performance evaluations – included only Brookfield, Westboro, and Windsor.

Brookfield, Westboro, and Windsor average is 2.7 compared to the 2.2 last CPR.

STAFF TURNOVER RATE (7/1/2011 – 6/30/2012)

STAFFING

Athol

Brook

field

Paxt

on

Wes

tbor

o

Winds

or

Cluster

Ave

rage

CSMA

CSNH

Overa

ll- C

RJ

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

31.80%

11.80%

33.30%36.80%

27.30% 28.20%

23.50%

15.40%

24.70%

Data obtained from HR Department & HR Personnel Summary

Average: 1.12 medication incidents and occurrences per client/month

Total of 142 medication incidents and occurrences (January – June 2012

Last CPR, average of 2.4 medication incidents/occurrences per client/month. Last CPR included Brookfield, Westboro and Windsor, only

MEDICATION INCIDENTS & OCCURRENCES

AtholBrookfield

PaxtonWestboro

WindsorOverall Cluster

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

0.11

4.1

00.03

0.830000000000001 1.12

Average Medication Incidents & Occurrences Per Month Per Client

Data obtained from MMRs

AtholBrookfield

PaxtonWestboro

Windsor

0

0.5

1

1.5

2

2.5

3

3.5

4

2.67

2.17

3.91

1.571.5

Average Clinical Hours Per Client /Month By Program

CLINICAL HOURS

Average of 2.42 clinical hours per client/month

Total Clinical Hours = 305 (January – June 2012)

Last CPR, average clinical hours per client per month was 1.5 Last CPR included Brookfield, Westboro and Windsor, only

Data obtained from MMRs

Clinical hours include in-house individual service hours and

in-house clinical group service hours.

AtholBrookfield

Paxton Westboro

WindsorCluster

0

5

10

15

20

25

30

0.330000000000001 2.03

2.25

22.43

1.23

6.50.483.03

2.38

26.3

7.9 8.67

Partici-pated In

COMMUNITY INCLUSION

Average of 6.5 community inclusion activities were participated in per client/month, compared to 2.77 at the last CPR. (Last CPR included Brookfield, Westboro and Windsor, only).

Total of 891 community inclusion activities were participated in by all clients. Average of 8.67 community inclusion activities were offered per client/month. Total of 1093

community inclusion activities were offered Jan – June 2012.

Average Community Inclusion Activities Participated In and Offered Per Client/ Month (January - June 2012)

Data obtained from MMRs

MAINSTREAM COMMUNITY ACTIVITIES

Average of 15.75 mainstream community activities participated in per client/month, compared to 3.46 at the last CPR (April –Sept. 2011). (Last CPR included Brookfield, Westboro and Windsor, only).

Total of 1985 mainstream activities were participated in by all clients. Average of 19.53 mainstream activities were offered per client/month; Total of 2462 mainstream activities were offered in Jan – June 2012.

Average Mainstream Activities Participated In and Offered Per Client/Month(January - June 2012)

Data obtained from MMRs

AtholBrookfield

PaxtonWestboro

WindsorCluster

0

5

10

15

20

25

30

12.03

22.33

9.1312.53

21.88

15.75

14.52

25.2

12.8815.96

29.22

19.53

ParticipatedOffered

DE-ESCALATIONS & RESTRAINTS

Data obtained from MMRs

De-Escalations : Restraints January – June 2012

Athol 5.62:1

Brookfield 10:1

Paxton 22:1

Westboro 124:1

Windsor 6.76:1

Average - Cluster 33.7:1

Total De-Escalations/Restraints for This Period

1079/101

ElopementsJanuary – June 2012

Athol 8

Brookfield 0

Paxton 0

Westboro 3

Windsor 2

Cluster Total

13

Previous CPR (April – Sept.2011), • Average Cluster Ratio = 16.6:1

• Brookfield 13.3:1• Westboro 13:1• Windsor 23.6:1

4 Elopements reported

STAFF TRAINING HOURS

AtholBrookfield

PaxtonWestboro

WindsorCluster

0

100

200

300

400

500

600

700

800

900

1000

218 243

370

32 92

955

20.8 24 39.43.4 8.8 19.3

Total Hours Completed By Program Average Per Staff

Data obtained from MMRs

Average 19.3 training hours per staff

Total 955 training hours were completed January – June 2012

Last CPR, total training hours = 1,068. (Last CPR included Brookfield, Westboro and Windsor, only).

RESULTS OF SQA MONITORING AUDITS

CONFIDENTIAL FILES AVERAGE = 74%Positives ISP Documents were completed 100% in 4 out of the 5

programs Satisfaction Surveys completed 100% (2011)

Areas to Improve LOM/Restraint forms and the Behavioral data do not match in

4 out of the 5 programs Mandatory medical appointments

◦ Annual Physical examination 80%◦ Dental exam 80%◦ Vision Exams 80%

Acquiring mandatory signatures on the proper forms

RESULTS OF SQA MONITORING AUDITS

FINANCIAL RECORDS AVERAGE = 87% Positives All Resident Funds records matched the amount of cash on hand

(100%) All bank books were balanced (100%)Areas to Improve Budgeting Sessions 20% being completed correctly Accuracy of the Funds Management Teaching plans

 PROGRAM FORMS AVERAGE = 80%Positives Fire drills completed (100%) and documented properly (91%) Up to date Safety plans with proper signatures (100%) Up to date

trainings (80%)Areas to Improve Up to date Carbon Monoxide training (40%) House meetings with proper documentation (40%)

Total of 22 clients in Randi’s Cluster Employment/Education: (as of June 30, 2012)

◦ 3 clients are employed◦ 4 enrolled in full-time education◦ 10 enrolled in sheltered workshops◦ 5 enrolled in pre-vocational or job training

Other:◦ Client incidents involving contraband was “0” this

reporting period. Last CPR, no contraband (“trigger items”) found in the programs.

KEY MMR RESULTS